Provider Demographics
NPI:1104853373
Name:WILBURN, KELLY TERRELL (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:TERRELL
Last Name:WILBURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:TERRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1428 DUNWOODY VILLAGE PKWY.
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338
Mailing Address - Country:US
Mailing Address - Phone:770-394-2358
Mailing Address - Fax:770-394-3055
Practice Address - Street 1:1428 DUNWOODY VILLAGE PKWY.
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-394-2358
Practice Address - Fax:770-394-3055
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054698208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA899642472BMedicaid